Inquest finds ambulance service failures contributed to death of Belfast man after four-hour wait

Systemic failings in Northern Ireland's ambulance and healthcare service contributed to the death of 25-year-old Lee Gannon after he waited nearly four hours for paramedics, an inquest in Belfast heard Tuesday.

Neil Sinclair, the ambulance service's chief paramedic officer, told the inquest that a failure to properly categorise the initial 999 call and broader operational pressures had fallen below the standard expected and had "tragic consequences" for Mr Gannon and his family. A post-mortem concluded Mr Gannon died from lobar pneumonia, a severe bacterial infection.

The court heard that Mr Gannon became unwell at his home in the Beechmount area of west Belfast in February 2022. His mother, Anne Gannon, dialled 999 after midnight reporting that her son was having breathing difficulties, could "barely get words out" and was speaking "gibberish." The initial call at 12:19 a.m. was coded as a Category 2 response after an emergency medical dispatcher (EMD) recorded the symptoms in a category linked to coronavirus, rather than the more urgent Category 1.

EMD Zena Gardner accepted that the call should have been given a Category 1 priority and told the court she "should have made it a Category 1." Asked why she had not, she said it was "an error of misunderstanding." A later special case review audit concluded that clarification about the patient's breathing effectiveness or level of consciousness could have triggered a different response.

A subsequent call taken by another EMD, Andrea Hunter, recorded the mother's report that Mr Gannon's breathing had worsened; Ms Hunter told the inquest she should have re-triaged the patient at that point and regretted not doing so. When a fourth call was made at 3:26 a.m., caller notes taken by James Bryant recorded deterioration including dehydration and unusual behaviour. Mr Bryant said he re-triaged the call but that the system retained the lower-priority categorisation alongside the higher category.

Paramedic Eamonn Cunningham, who later attended the scene, said he found Mr Gannon lying on the living-room floor with his father attempting CPR. Mr Gannon had no pulse; he was taken to the Royal Victoria Hospital, arriving at 4:13 a.m., where he was later pronounced dead after a cardiac arrest attributable to the severe infection.

Mr Sinclair told the inquest that handover delays at emergency departments had worsened, with ambulance crews often forced to wait outside hospitals for long periods until there was capacity inside. Those delays, he said, increased risk for other patients requiring ambulance responses and created the conditions for patient harm of the type that occurred in Mr Gannon's case. He offered a sincere apology for the ambulance service's actions.

The inquest heard that training has since been provided to staff on re-triage processes, with particular emphasis on clarifying breathing status and levels of alertness. EMDs are being encouraged to be alert to new information and to reclassify calls when a patient's condition changes.

Coroner Maria Dougan concluded the two days of evidence on Tuesday and will deliver formal findings at a later date. Mr Gannon's family has said he was "a beautiful soul" who was loved by everybody, and previously told the court medical experts had expressed the view that Mr Gannon would probably have survived if treated more promptly.

The case highlights ongoing operational strain on emergency services in Northern Ireland. EMDs told the court that the service had been under significant pressure on the night in question and that the situation has subsequently become worse, with callers increasingly advised to take relatives to hospital by car when appropriate to secure faster treatment. The inquest will inform the coroner's formal conclusions and any recommendations aimed at preventing similar outcomes in future.